Provider Demographics
NPI:1861626574
Name:BONZELET, MATTHEW J (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:J
Last Name:BONZELET
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 HIGHLANDS PLAZA DR E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1350
Mailing Address - Country:US
Mailing Address - Phone:314-367-3113
Mailing Address - Fax:
Practice Address - Street 1:1110 HIGHLANDS PLAZA DR E
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1350
Practice Address - Country:US
Practice Address - Phone:314-367-3113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2016-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI55456-20207R00000X
MO2012021730207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program